Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs

BACKGROUND

The 5.8 million Ukrainian refugees arriving in European countries must navigate varying healthcare systems and different and often unknown languages in their respective host countries. To date, there has been little exploration of the experiences, perceived differences, information and support needs of these refugees regarding the use of healthcare in Germany.

METHODS

We conducted ten qualitative interviews with Ukrainian refugees living in Germany from February to May 2023, using Ukrainian, English and German language. The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker with the MAXQDA software.

RESULTS

In general, participants consistently had a positive experience of the German healthcare system, particularly regarding the quality of treatments and insurance. Differences have been reported in the structure of the healthcare systems. The Ukrainian healthcare system is divided into private and state sectors, with no mandatory insurance and frequent out-of-pocket payments. Pathways differ and tend to focus more on clinics and private doctors. General practitioners, often working in less well-equipped offices, have only recently gained prominence due to healthcare system reforms. Initiating contact with doctors is often easier, with much shorter waiting times compared to Germany. Interviewees often found the prescription requirements for many medications in Germany to be unusual. However, the mentioned differences in healthcare result in unmet information needs among the refugees, especially related to communication, navigating the healthcare system, health insurance, waiting times and medication access. These needs were often addressed through personal internet research and informal (social media) networks because of lacking official information provided during or after their arrival.

CONCLUSIONS

Despite the positive experiences of Ukrainian refugees in the German healthcare system, differences in the systems and language barriers led to barriers using healthcare and information needs among refugees. The dissemination of information regarding characteristics of the German health care system is crucial for successful integration but is currently lacking.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00030942, date of registration: 29.12.2022.

Opioid Use Disorder: A Qualitative Exploratory Analysis of Potential Misunderstandings in Patients with Chronic Non-Cancer Pain

Purpose

Substance use disorders (SUD) are a challenging comorbidity in patients with chronic non-cancer pain (CNCP) as they complicate diagnosis and therapy, especially when opioids are part of the therapeutic regimen. A definite diagnosis of opioid use disorder (OUD) in patients with CNCP on long-term opioid therapy (LTOT) is a prerequisite for effective and targeted therapy but may be complicated as some criteria of OUD might be attributed to the desire of the patient to relieve the pain. For instance, the desire to increase the dose can be based on both a SUD as well as inadequate pain therapy. Many scientific studies use standardized questions. Therefore, potential misunderstandings due to possible diagnostic overlaps often cannot be clarified.

Methods

14 qualitative guided interviews were conducted and analyzed (Kuckartz content analysis), with the intention to verify if patient's initial response to simple questions based on the wording of the DSM-5, as commonly used in research and practice, were consistent with the results of a more in-depth inquiry.

Results

The results suggest that without in-depth investigation, there is a particular risk of false-positive assessment of the DSM-5 criteria for OUD when opioids are prescribed, especially when the questions are considered independently of chronic pain. The risk of a false-negative assessment has also been shown in isolated cases.

Conclusion

Only after asking for and describing specific situations it was possible to determine whether the patient's positive or negative answers were based on a misunderstanding of the question. To avoid misdiagnosis, staff conducting DSM-5 interviews should be trained in pain-specific follow-up questions that may help to uncover diagnostic confounding.

[Multimorbidity and its Importance in Future Health Care in Germany: a Secondary Data Analysis Based on 67 Million Health Insurance Policy Holders]

BACKGROUND

Multimorbidity is a particular challenge for health care systems. In Germany, epidemiological findings are primarily sample-based. The estimated prevalence among adults in Germany is high, but there are methodological problems, such as a lack of a uniform definition.

METHOD

Statutory health insurance data from the information system for health care data ("Informationssystem Versorgungsdaten") of the former German Institute for Medical Documentation and Information were analyzed. A total of 67.3 million people with statutory health insurance in 2014 were included. Multimorbidity was defined by the presence of at least three chronic diseases from a list of 46 diseases per ICD-10.

RESULTS

A total of 21,157,937 individuals, or 31.4% of the total cohort, were defined as multimorbid. In men, progression of multimorbidity occurred at the age of about 40 years, whereas the increase was seen at the age of about 35 years in women. The different disease burden varied in different age and sex groups.

CONCLUSION

A better understanding of complex disease interactions in relation to age and sex is needed. Interdisciplinary approaches with specific care concepts for multimorbidity, adapted to the chronic care model, should be explored in order to achieve an ideal care situation in Germany.

[Changes in Prescription Patterns of Oral Anticoagulants in Family Practices after Marketing Approval of Direct Oral Anticoagulants]

AIM OF THE STUDY

Since 2011, non-vitamin-K-dependent oral anticoagulants (NOAC) have extended the spectrum of anticoagulation therapy. Initially, the approval of NOAC was limited to the prophylaxis of postoperative thrombosis, but in the course of time the spectrum was extended to the therapy of thrombosis and embolism as well as anticoagulation in non-valvular atrial fibrillation. The study was designed to examine how the approval of NOAC had affected the prescribing behaviour of general practitioners in the first years of their approval.

METHODS

In a retrospective longitudinal study, the prescriptions of anticoagulants between 2012 and 2017 were analysed in 3 general practitioners' practices in the Bonn area. The study included all patients for whom at least one prescription from a NOAC or a vitamin K antagonist (VKA) was documented in the administrative system of the practices during this period.

RESULTS

A total of n=579 patient files were evaluated (47% female; median age 75 years). Of these, 47% received a VKA, and 40% a NOAC (59% rivaroxaban, 29% apixaban, 9% dabigatran and 3% edoxaban). During the period under examination, the share of VKA prescriptions decreased from 45% to 14% and the share of NOAC increased from 28% to 87%. Anti-coagulation was changed in 12%. The most frequent change was from a VKA to a NOAC (70%).

CONCLUSION

After marketing approval, the use of NOAC in the initial prescriptions increased steadily. This trend can also be seen in other European studies. VKA are mainly prescribed to patients with stable oral anticoagulation. As recommended in the guidelines, anticoagulation is changed mainly when problems occur during therapy. If the trend in the prescription of anticoagulants continues, in the medium term, VKA will only be prescribed for patients who have been stable for many years and for patients with artificial heart valves.

[Primary care of Ukrainian refugees]

Background

Since the beginning of the war in Ukraine, more than 7.6 million people from Ukraine have been registered as refugees in European countries. In Germany, the number is estimated to be more than 1 million. These refugees may have different health needs than German patients due to differences in the health care system, disease prevalence, preventive measures, health behavior, and experiences of flight. However, general practitioners (GPs) have hardly been prepared for the contact.

Objectives

For the first time, challenges in the treatment of Ukrainian refugees and support needs of German GPs were determined.

Materials and methods

In July and August 2022, a cross-sectional study among GPs in Germany was conducted using an online survey.

Results

A total of 82 GPs participated with a response rate of 16.0%; 52 of the participating GPs had treated Ukrainian refugees in the previous 2 weeks. In all, 75.0% of them reported difficulties or peculiarities in care, especially in communication (61.5%), due to lack of information about previous illnesses (34.6%), and expectations of services to be provided (30.8%). Of the 82 participants, 59.8% reported a need for multilingual information for patients, especially about the German health care system, help with mental health problems, contact points, and differences in the use of medications. Information for the practice team is needed in 37.8% of cases, especially on possibilities in case of language barriers, vaccination coverage in Ukraine, and dealing with missing vaccination records as well as drug lists.

Conclusions

Due to the new situation of Ukrainian refugees in Germany and the mentioned barriers, GPs should be supported in care. Information for practice teams as well as their networking with psychotherapeutic offers, contact points, drug databases, and regional interpreter services are urgently needed. However, multilingual information for Ukrainian patients should be disseminated in order to relieve the burden on practices, which have been under great strain, and to ensure continuity and quality of care.

[General practitioners' perception of integrated care using communication technologies: a secondary analysis of a focus group of the Horizon 2020 funded project POLYCARE]

BACKGROUND

Integrated healthcare models (IC) have the objective of reducing the costs of an increased use of health service as well as the strong sectoral fragmentation of the German health care system. However, no national approach has been implemented in primary care to date.

METHOD

Ten GPs from the Cologne/Bonn district (60% male; Ø age = 52 years [35-65]) were invited to a focus group in 2016. The interview was part of the Horizon 2020 funded POLYCARE study. A semi-structured guideline was used to assess feasibility of the POLYCARE study protocol. GPs also provided information about previous experience with and attitudes toward IC models and the relevant information and communication technologies (ICT), such as home-monitoring or communication software. This information was analyzed using a transcending secondary analysis to evaluate conditions for their successful implementation.

RESULTS

Participants reported little experience with IC and ICT. However, they reported being open to both and seeing potential for time savings, better networking opportunities, and increased quality of care for their patients. The integration of social services was considered as a chance of alleviating the burden of socio-medical tasks. Barriers to the introduction of IC and ICT were seen in the initial time investment, the lack of legal structures, the concern about overabundant data, and the susceptibility to failure.

CONCLUSION

The nationwide expansion of social services as well as ICT that is easy to use, less susceptible to failure, and compatible with existing structures show great potential for relieving GPs. Future research should address the concerns - such as financial and time expenses of introducing IC and ICT - of GPs by systematic investigation in long-term studies. The provision of an additional legal basis that is regulating the respective remuneration models as well as the rights and obligations of all parties, IC and ICT can play a greater role in future patient care.

Burden Associated with Telephone Calls on COVID-19: Results of a Flash Mob Study in Family Practices

Background

Family practices are the primary contact for inquiries relating to COVID-19. This study reveals the reasons why German family practices are called during the pandemic and which burden is associated with patients' inquiries related to COVID-19 among practice assistants (PAs).

Methods

On April 28, 2021 a cross-sectional flash mob study was conducted in family practices across Germany. The study material and invitation were disseminated via social media and postal or electronic mails. During half a day, participating practices counted every incoming call. For calls addressing COVID-19, the reason, duration, and perceived stress level were documented. Descriptive statistics and regression analyses were performed using SPSS.

Results

5,646 calls, 1,826 of which were related to COVID-19 (32.3%), were documented by 73 practices (practice average: 25.0 ± 17.7) within a single Wednesday morning. Most calls addressed vaccination (n = 1,050, 59.0%). During 22.0% (n = 388) of COVID-19-related calls, PAs felt stressed, which was mainly influenced by the call duration (calls of 5 minutes and longer were perceived significantly more stressful [OR 8.94, 95% CI 6.47-12.37]). Feeling well-prepared to meet patients' inquiries relating to COVID-19 was a protective factor for the average stress perceived per PA. Overall, less than 10% of calls on COVID-19 were transferred to a physician.

Conclusions

Family practice teams experience a high volume of partly stressful phone calls about COVID-19 but are often able to handle the pandemic challenges. PAs play a central role in advising the practice population on issues related to COVID-19. This deserves greater recognition.

Specialized Outpatient Palliative Care—Clinical Course and Predictors for Living at Home Until Death

BACKGROUND

Specialized outpatient palliative care (SOPC) is an important component of the palliative medicine care concept in Germany. Its purpose is to improve the out-of-hospital care of patients who cannot be adequately cared for by their primary care physicians and in the setting of general outpatient palliative care (GOPC).

METHODS

In this retrospective analysis of anonymized routine treatment data, we analyzed the characteristics of SOPC patients overall and with specific diseases, and depicted them both numerically and graphically. We also carried out a regression analysis of the factors affecting whether or not patients will be able to die in a home environment.

RESULTS

The analysis included data from 14 460 patients who were treated by 14 different SOPC teams in the North Rhine area of Germany in 2017 and 2018. The majority of patients who died were able to live at home until death (85.9%); only a small percentage died as inpatients (7.7%). The symptom burden shortly before death was less than at the beginning of treatment. The factors displaying a statistically significant association with dying at home were: more advanced age (aOR 0.96; 95% CI: [0.95; 0.96]), female sex (aOR 0.85; 95% CI: [0.74; 0.98]), and house calls at night (aOR 0.60; 95% CI: [0.51; 0.71]).

CONCLUSION

SOPC met its declared objectives of limiting distressing symptoms and enabling patients to live at home until death.

Patients' perspective on supposedly patient-relevant process and outcome parameters: a cross-sectional survey within the 'PRO patients study'

BACKGROUND

To be able to make informed choices based on their individual preferences, patients need to be adequately informed about treatment options and their potential outcomes. This implies that studies measure the effects of care based on parameters that are relevant to patients. In a previous scoping review, we found a wide variety of supposedly patient-relevant parameters that equally addressed processes and outcomes of care. We were unable to identify a consistent understanding of patient relevance and therefore aimed to develop an empirically based concept including a generic set of patient-relevant parameters. As a first step we evaluated the process and outcome parameters identified in the scoping review from the patients' perspective.

METHODS

We conducted a cross-sectional survey among German general practice patients. Ten research practices of Witten/Herdecke University supported the study. During a two-week period in the fall of 2020, patients willing to participate self-administered a short questionnaire. It evaluated the relevance of the 32 parameters identified in the scoping review on a 5-point Likert scale and offered a free-text field for additional parameters. These free-text answers were inductively categorized by two researchers. Quantitative data were analyzed using descriptive statistics. Bivariate analyses were performed to determine whether there are any correlations between rating a parameter as highly relevant and patients' characteristics.

RESULTS

Data from 299 patients were eligible for analysis. All outcomes except 'sexuality' and 'frequency of healthcare service utilization' were rated important. 'Confidence in therapy' was rated most important, followed by 'prevention of comorbidity' and 'mobility'. Relevance ratings of five parameters were associated with patients' age and gender, but not with their chronic status. The free-text analysis revealed 15 additional parameters, 12 of which addressed processes of care, i.e., 'enough time in physician consultation'.

CONCLUSION

Patients attach great value to parameters addressing processes of care. It appears as though the way in which patients experience the care process is not less relevant than what comes of it. Relevance ratings were not associated with chronic status, but few parameters were gender- and age-related.

TRIAL REGISTRATION

Core Outcome Measures in Effectiveness Trials Initiative, registration number: 1685.

Ausgestaltung und Barrieren für eine Tabakentwöhnung in Hausarztpraxen: Ergebnisse einer qualitativen Studie

Ziel der Studie Etwa 25% der deutschen Bevölkerung raucht. Obgleich Tabakentwöhnung eines der effektivsten Mittel zur Reduktion tabakassoziierter Folgen ist, findet sie nicht ihren Weg in die Regelversorgung. Auch in Hausarztpraxen wird sie nur vereinzelt angeboten. Diese Studie untersucht, wie Hausärztinnen und Hausärzte mit dem Thema Tabakentwöhnung umgehen und welche Faktoren die Umsetzung von Tabakentwöhnung behindern.

Methodik Es wurden leitfadengestützte Einzelinterviews mit 13 LehrärztInnen des Instituts für Hausarztmedizin in Bonn geführt. Die Interviews wurden auf Tonband aufgezeichnet und transkribiert. Anhand des Textmaterials erfolgte in MAXQDA eine inhaltlich strukturierende Inhaltsanalyse mit deduktiv-induktiver Kategorienbildung.

Ergebnisse Die HausärztInnen berichten verschiedene Arten, wie sie Tabakentwöhnungsmaßnahmen in der Praxis umsetzen, wobei sie kombinierte Ansätze als erfahrungsgemäß effektiv beschreiben. Nikotinersatztherapie und verschreibungspflichtige Mittel behalten sie starken Rauchern mit erfolglosen Entwöhnungsversuchen vor. Ihrer Erfahrung nach ist der Wirkstoff Vareniclin sehr wirksam und gut verträglich. Dennoch berichten die HausärztInnen einen zurückhaltenden Einsatz, da sie infolge der Warnhinweise für den Wirkstoff Bupropion auch Nebenwirkungen bei Vareniclin befürchten. Als zentrale Barrieren für Tabakentwöhnung sehen sie praxisseitigen Zeitmangel, fehlende Patientenmotivation und Kosten für medikamentöse Ansätze.

Schlussfolgerung Die befragten HausärztInnen möchten gerade ihren motivierten PatientInnen zum Rauchstopp verhelfen. Jedoch fehlt eine strukturierte Behandlung der Tabakabhängigkeit. Dadurch ist die Anzahl an Raucherinterventionen gering und wirksame Therapien werden zu selten eingesetzt. Der Aufwand einer strukturierten Behandlung müsste jedoch finanziell entlohnt werden. Zudem könnten die HausärztInnen durch den Ausbau von externen Angeboten zur Tabakentwöhnung zeitlich entlastet werden.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis

Background: Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED.Methods: Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.).Results: A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm's positive/negative predictive values (95% confidence interval) were 0.80 (0.28-0.99)/1.00 (0.92-1.00) and 0.75 (0.19-0.99)/0.98 (0.88-1.00) for detection of any DED and referral-warranted DED, respectively.Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI.Conclusions: Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

Factors influencing length of survival in ambulatory palliative care - a cross sectional study based on secondary data

BACKGROUND

Quality of life and patient self-determination are key elements in successful palliative care. To achieve these goals, a robust prediction of the remaining survival time is useful as it can provide patients and their relatives with information for individual goal setting including appropriate priorities. The Aim of our study was to assess factors that influence survival after enrollment into ambulatory palliative care.

METHODS

In this cross-sectional, multicenter study (n = 14 study centers) clinical records of all palliative care patients who were treated in 2017 were extracted and underwent statistical analysis. The main outcome criterion was the association of survival time with clinical characteristics such as age, type of disease, symptoms and performance status.

RESULTS

A total of 6282 cases were evaluated. Median time of survival was 26 days (95 % CI: 25-27 days). The strongest association for an increased hazard ratio was found for the following characteristics: moderate/severe weakness (aHR: 1.91; 95 % CI: 1.27-2.86) Karnofsky score 10-30 (aHR: 1.80; 95 % CI: 1.67-1.95), and age > 85 (aHR: 1.50; 95 % CI: 1.37-1.64). Surprisingly, type of disease (cancer vs. non-cancer) was not associated with a change in survival time (aHR: 1.03; 95 % CI: 0.96-1.10).

CONCLUSIONS

In this cross-sectional study, the most relevant predictor for a short survival time in specialized ambulatory palliative care was the performance status while type of disease was irrelevant to survival.

Risk factors for a positive SARS-CoV-2 PCR in patients with common cold symptoms in a primary care setting - a retrospective analysis based on a joint documentation standard

Background

Combating the COVID-19 pandemic is a major challenge for health systems, citizens and policy makers worldwide. Early detection of affected patients within the large and heterogeneous group of patients with common cold symptoms is an important element of this effort, but often hindered by limited testing resources, false-negative test results and the lack of pathognomonic symptoms in COVID-19. Therefore, we aimed to identify anamnestic items with an increased/decreased odds ratio for a positive SARS-CoV-2 PCR (CovPCR) result in a primary care setting.

Methods

We performed a multi-center cross-sectional cohort study on predictive clinical characteristics for a positive CovPCR over a period of 4 weeks in primary care patients in Germany.

Results

In total, 374 patients in 14 primary care centers received CovPCR and were included in this analysis. The median age was 44.0 (IQR: 31.0–59.0) and a fraction of 10.7% (n = 40) tested positive for COVID-19. Patients who reported anosmia had a higher odds ratio (OR: 4.54; 95%-CI: 1.51–13.67) for a positive test result while patients with a sore throat had a lower OR (OR: 0.33; 95%-CI: 0.11–0.97). Furthermore, patients who had a first grade contact with an infected persons and showed symptoms themselves also had an increased OR for positive testing (OR: 5.16; 95% CI: 1.72–15.51). This correlation was also present when they themselves were still asymptomatic (OR: 12.55; 95% CI: 3.97–39.67).

Conclusions

Several anamnestic criteria may be helpful to assess pre-test probability of COVID-19 in patients with common cold symptoms.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12875-020-01322-7.

[Specialized Outpatient Palliative Care: Results of a Cross-Sectional Study]

OBJECTIVE

Specialized outpatient palliative care (SAPV) is an important component in the care of people in their final days of life in Germany. The analysis of a representative cohort allows important conclusions to be drawn for improving the situation of people in palliative care in Germany.

METHODS

We analyzed the routine data of 2691 palliative patients collected during the care of an SAPV team. Statistical analyses were performed using SPSS version 24.

RESULTS

In SAPV, approximately three-fourths of patients died in their homes. Of the total of 2691 patients, 1972 suffered from a malignancy and 719 patients had a non-malignant, chronic disease. The age at first contact with SAPV was significantly higher in patients without malignancy. Patients with or without malignancy did not differ from each other in terms of quality of life (Karnofsky's score) or symptom frequency. Only disorientation was documented significantly more frequently in non-tumor patients and was also more pronounced.

CONCLUSION

SAPV enables the fulfilment of the wish of most patients to die in their homes.

Association between over-indebtedness and antidepressant use: A cross-sectional analysis

Background

Burden of disease caused by depression and its association with socioeconomic status is well documented. However, research on over-indebtedness is scarce although millions of European citizens in all socioeconomic positions are over-indebted. Prior studies suggested that over-indebtedness is associated with poor physical and mental health.

Aims

Investigate the association between over-indebtedness and antidepressant use in Germany.

Method

A cross-sectional survey among debt advice agencies’ clients was conducted in North Rhine-Westphalia, Germany, in 2017 (OID). Data were merged with the first wave of the German Health Interview and Examination Survey for Adults (DEGS1). Descriptive statistics and logistic regression analysis were used to examine antidepressant use in the previous 7 days (OID: n = 699; DEGS1: n = 7115).

Results

Prevalence of antidepressant use was higher in the over-indebted (12.3%) than the general population (5.0%). The over-indebted were significantly more likely to use antidepressants than the general population even after controlling for other socioeconomic, demographic and health factors (adjusted odds ratio 1.83; 95% confidence interval 1.35–2.48).

Conclusions

Stakeholders in health care, debt counselling, research and social policy should consider the link between over-indebtedness and mental illness to advance the understanding of health inequalities and to help those who have mental health and debt problems.

Rate of opioid use disorder in adults who received prescription opioid pain therapy-A secondary data analysis

Background and aims

Data on rates of prescription opioid use disorder (pOUD) in European countries is limited. The aim of this investigation was to analyze a representative population sample regarding the 1-year prevalence of opioid use disorder in patients who received prescription opioid pain therapy and to identify related risk factors.

Design

Cross-sectional secondary data analysis

Setting

Secondary data analysis based on data from the 2015 Epidemiological Survey of Substance Abuse (ESA 2015) in Germany

Participants

German-speaking individuals living in private households aged 18 to 64 years were investigated. A total of 9204 individuals participated in the survey, resulting in a response rate of 52.2%.

Primary and secondary outcome measures

Primary outcome measure was the weighted prevalence of pOUD in the subgroup of study participants who had received prescription opioids. Secondary outcome measure was an analysis of risk factors connected with pOUD in the same subgroup.

Findings

A total of n = 9204 participants were included in the study of which n = 275 had received an opioid prescription in the last 12 months of which n = 54 were diagnosed with pOUD. The weighted 1-year prevalence of pOUD was 21.2% (mild: 14.7% | moderate: 3.5% | severe: 2.9%). Participants who had received opioid pain therapy had significantly higher odds of pOUD if they reported signs of depression (OR: 2.69; CI 95%: 1.13–6.38), inexplicable physical complaints (OR: 2.68; CI 95%: 1.14–6.31) or a psychiatric diagnosis (OR: 4.12; CI 95%: 1.36–12.43), and significantly lower odds of pOUD if they reported the use of non-opioid painkillers (OR: 0.27; CI 95%: 0.09–0.81).

Conclusions

pOUD is a common phenomenon in working-age patients who receive prescription opioid pain therapy in Germany and may be related to the co-existence of psychosomatic and psychiatric disorders such as depression.

[COVID-19 in the nursing home: a case report]

Dieser Beitrag schildert, wie eine Pflegeeinrichtung in Zeiten der Corona-Pandemie auf potenzielle und reale SARS-CoV-2-Infektionen reagiert.

Patient-physician communication about financial problems: A cross-sectional study among over-indebted individuals

Background

About every tenth household across Europe is unable to meet payment obligations and living expenses on an ongoing basis and is thus considered over-indebted. Previous research suggests that over-indebtedness reflects a potential cause and consequence of psychosomatic health problems and limited access to care. However, it is unclear whether those affected discuss their financial problems with general practitioners. Therefore, this study examined patient-physician communication about financial problems in general practice among over-indebted individuals.

Methods

We conducted a cross-sectional survey among clients of 70 debt advice agencies in North Rhine-Westphalia, Germany, in 2017. We assessed the prevalence of patient-physician communication about financial problems and its association with patient characteristics using descriptive statistics and logistic regression analysis. Of 699 individuals who returned the questionnaire (response rate:50.2%), we included 598 respondents enrolled in statutory health insurance with complete outcome data in the analyses.

Results

Conversations about financial problems with general practitioners were reported by 22.6% (n = 135) of respondents. Individuals with a high educational level were less likely to report such conversations than those with medium educational level (aOR 0.11; 95%CI 0.01–0.83) after adjustment for other sociodemographic characteristics, health status and measures of financial distress. Those without a migrant background(aOR 2.09; 95%CI 1.32–3.32), the chronically ill(aOR 1.90; 95%CI 1.16–3.13) and individuals who reported high financial distress(aOR 2.15; 95%CI 1.22–3.78) and cutting on necessities to pay for medications(aOR 1.86; 95%CI 1.12–3.09) were more likely to discuss financial problems than their counterparts.

Conclusions

Few over-indebted individuals discussed financial problems with their general practitioner. Patients’ health status, coping strategies and perception of financial distress might contribute to variations in disclosure of financial problems. Thus, enhancing communication and screening by routine assessment of financial problems in clinical practice can help to identify vulnerable patients and promote access to health care and social services and well-being for all.

Coronavirus — Aktuelle Empfehlungen für den Hausarzt

Innerhalb kurzer Zeit hat sich die Coronavirusinfektion COVID-19 zu einer weltweiten Pandemie entwickelt, die auch den Hausarzt vor große Herausforderungen stellt. Auf Basis der aktuellen Kenntnislage hat die Deutsche Gesellschaft für Allgemeinmedizin (DEGAM) praktische Handlungsempfehlungen entwickelt. MMW-Schriftleiter Prof. Klaus Weckbecker stellt zusammen mit Dr. Johannes Just die Leitlinie im folgenden Report vor.

Klug entscheiden

In dieser zum nun abgesagten Internistenkongress 2020 geplanten MMW-Ausgabe legen wir den Schwerpunkt — wie könnte es anders sein — auf die Infektiologie.

Phenprocoumon Dose Requirements, Dose Stability and Time in Therapeutic Range in Elderly Patients With CYP2C9 and VKORC1 Polymorphisms

Background

Dose requirements of vitamin K antagonists are associated with CYP2C9 and VKORC1, but, compared to warfarin, less data is available about phenprocoumon. Furthermore, the effects on dose stability and anticoagulation quality are still unclear.

Methods

Aim was to scrutinize phenprocoumon dose requirements, dose stability and anticoagulation quality in association to CYP2C9 and VKORC1 in a natural cohort of elderly primary care patients. As a subgroup within the IDrug study, phenprocoumon treated patients with at least two INR values within three months before enrollment (n = 209) were analyzed concerning average weekly dose, standard deviation of weekly dose (intra-subject variability), constant dose (yes/no), average INR and TTR grouped by CYP2C9 and VKORC1 (and combinations).

Results

Average weekly dose per patient was 14.4 ± 5.3 mg, 11.9 ± 4.0 mg and 11.2 ± 4.3 mg in CYP2C9 wildtypes, *2 and *3 carriers (p < .0001) and 16.0 ± 4.2 mg, 13.3 ± 5.1 mg and 8.0 ± 2.7 mg per week in VKORC1 CC, CT and TT genotypes, respectively (p < .0001). Significant differences concerning intra-subject variability were detected among all groups (p < .0001) with the smallest variability in CYP2C9*3 carriers. TTR medians were 75.4%, 79.4% and 100% in wildtypes, *2 and *3 carriers, respectively (p = 0.0464). The proportion of patients with perfect control was highest among *3 carriers, but this result was not significant (p = 0.0713).

Discussion

Our analyses support the results of previous investigations regarding genotype-associated dose requirements and raise the hypothesis that dose stability and anticoagulation quality may be increased in CYP2C9*3 carriers. However, our data should be treated cautiously due to the small sample size.

Clinical Trial Registration

German Clinical Trials Register, identifier DRKS00006256.

[Addressing Issues of Living Will and Power of Attorney in Patients With Dementia - A Cross-Sectional Study Among German General Practitioners]

OBJECTIVES

Issues of living will and power of attorney must be addressed as early as possible in dementia patients because of their decreasing independence and ability to act for themselves. The aim of this study was to investigate whether general practitioners (GPs), who usually have long-standing and regular contact with this group of patients, address these precautionary measures and if there is any association between this approach and further communication and educational behaviour of doctors.

METHODS

A cross-sectional survey, using standardized, written questionnaires, was conducted in a random sample of 982 GPs in North Rhine-Westphalia in western Germany between October 2017 and January 2018. Descriptive statistical as well as logistic regression analyses were carried out using IBM SPSS Statistics, version 24.

RESULTS

A total of 339 GPs responded to the survey questionnaire (response rate: 34.5%). A majority of GPs (70.1%) agreed totally or partially that it was necessary to address their dementia patients on living will and power of attorney; GPs who were more confident in communicating a dementia diagnosis reported addressing the issue of documents for the end of life more frequently (aOR: 1.97; 95%-CI: 1.17-3.33). Older GPs with greater knowledge of regional services for dementia patients also tended to address this topic more frequently.

CONCLUSIONS

General practitioners make a major contribution to help dementia patients and their relatives to plan ahead at an early stage of the disease. It can be concluded from our results that GPs' knowledge and experiences about dementia and local services, as well as how to deal with those affected should be improved in order to optimise communication on living will and power of attorney as precautionary measures.

[Prevalence of sleep apnea in patients with first diagnosis of hypertension]

BACKGROUND AND OBJECTIVES

The risk of obstructive sleep apnea (OSA) is significantly increased in patients with hypertension. In addition, OSA appears to be an independent cardiovascular risk factor. So far, sleep apnea screening is only recommended for patients with refractory hypertension and history of OSA. Therefore, OSA often remains undiagnosed in hypertensive patients. The underlying prevalence data are mainly from outpatient hypertension clinics. Data on the prevalence of OSA in patients with hypertension in primary care are not yet available. Due to the cardiovascular risk, some experts recommend screening for OSA when high blood pressure is diagnosed. The study presented here describes for the first time the prevalence of OSA in GP patients immediately after the initial diagnosis of hypertension.

METHOD

6 family practices participated in the study between December 2012 and April 2014. Cardiorespiratory polygraphy was performed on all patients diagnosed with hypertension during this period using a 24-hour blood pressure monitor (ABPM). A sleep physician evaluated the polygraphy data online.

RESULTS

50 patients were recruited, 6 patients did not meet the inclusion criteria. Thus, the data of 44 patients (19 women) were analyzed. An obstructive sleep apnea was diagnosed in 34% (n = 15) of the patients. 16% (n = 7) had a mild OSA, 16% (n = 7) a moderate OSA and 2% (n = 1) a severe OSA.

CONCLUSIONS

In a relevant proportion of patients with newly diagnosed hypertension, an undiagnosed OSA was found. In order to estimate the possible effects of sleep apnea screening on hypertension patients, representative studies in the primary medical field are required.

Over-indebtedness and its association with pain and pain medication use

In developed countries, millions of households are over-indebted, and the number continues to rise. Studies have found an increased risk of adverse health effects among individuals that cannot cover payment obligations with available assets persistently. However, little is known about the role of over-indebtedness in pain. This study examined the association between over-indebtedness and pain and pain medication use. A cross-sectional study conducted among over-indebted individuals in 70 debt advisory centres in Germany (OID-survey; n = 699) was linked to the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). Descriptive statistics and logistic regression analyses were used to examine the association between over-indebtedness and pain and pain medication use among participants with valid data on both outcome variables (n = 7560). Pain was experienced by over-indebted individuals more frequently (71.3%) compared to the general population (59.6%) whereas the prevalence of pain medication use was similar in both samples (DEGS1 12.6% vs. OID-survey 13.1%). Over-indebtedness significantly increased the odds of pain (aOR 1.30; 95%-CI 1.07-1.59) after adjusting for socioeconomic, demographic and health factors. The over-indebted were significantly less likely to use pain medication compared to the general population after adjustment (aOR 0.76; 95%-CI 0.58-0.99). Taking over-indebtedness into account as risk factor for pain and restricted pain medication use in research and clinical practice will help to advance the understanding of pain disparities, develop suitable interventions for preventive action and promote accessible pain management among those at risk.

Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study

Background

Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.

Methods

In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).

Results

The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.

Conclusions

Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.

Trial registration

Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Antidepressant use in over-indebted individuals compared to the general population in Germany

Background

About ten percent of European households across all socioeconomic groups are considered over-indebted due to ongoing difficulties meeting financial commitments and living expenses. Studies found an association between over-indebtedness and physical and mental health such as depression independent of standard socioeconomic status measures. However, antidepressant use in the over-indebted population has been understudied. In view of the substantial economic and social burden of mental illness in Europe, the aim of this study was to examine the association between over-indebtedness and antidepressant use in Germany to advance the understanding of socioeconomic inequalities in mental health.

Methods

We conducted a cross-sectional survey among clients of 70 debt advice agencies in North Rhine-Westphalia, Germany, in 2017 (OID), and merged data with the first wave of the German Health Interview and Examination Survey (DEGS1) representative of the general population. We used descriptive statistics and multiple logistic regression analysis to examine antidepressant use in the previous 7 days (OID: n = 699; DEGS1: n = 7115).

Results

Antidepressant use was more frequent in the over-indebted (12.3%) compared to the general population sample (5.0%). After adjustment for age, sex, education, employment, marital status and chronic disease, over-indebted respondents were more likely to use antidepressants than the general population sample (aOR 1.83; 95% CI 1.35-2.48).

Conclusions

Prevalence of antidepressant use was higher in the over-indebted compared to the general population. The association between over-indebtedness and antidepressant use cannot be fully explained by standard socioeconomic measures. Over-indebtedness reflects a relevant public health issue that needs to be addressed in health care, social policy and research. There is an urgent need to develop public health activities that specifically target those at risk of mental illness and over-indebtedness.

Key messages

Over-indebtedness is associated with antidepressant use. Public health interventions are needed to prevent adverse health effects of over-indebtedness and safeguard access to care according to need.

[Information brochure for relatives of people with severe illness - acceptance and feasibility]

BACKGROUND

Family members of patients with severe illness are burdened with the care and participation in challenging decisions regarding medical treatment and care in addition to the challenges of their own lives. They express a wish for low-threshold support services. However, there are few publications on targeted interventions for the support of family members of patients with a serious illness.

METHOD

An information brochure was developed on the basis of a systematic review and its feasibility and acceptance were tested with an evaluation sheet, handed out to family members in 3 different settings (3 palliative care units, 21 family practices, and 2 home palliative care services) over a period of 6 weeks. Satisfaction was measured using a 5-point Likert scale (1 = very satisfied, 5 = not satisfied at all). To assess the acceptance of the brochure the participants were asked about their willingness to read. The benefit was judged on questions of information gain. In addition, deficiencies could be named and suggestions for improvement could be made.

RESULTS

Overall, 27 evaluation sheets were analysed. 93% of the participating relatives read the whole brochure. 63% of the relatives were satisfied or very satisfied with the flyer (median 2 = satisfied). 70% of the relatives said they had received new information.

CONCLUSIONS

In this feasibility study, the acceptance and usefulness of the information flyer for a large number of relatives was confirmed. Such an information flyer thus provides a low-threshold supplement to the support of families in the care at the end of life.

Over-indebtedness and its association with sleep and sleep medication use

BACKGROUND

Over-indebtedness is currently rising in high-income countries. Millions of citizens are confronted with the persistent situation when household income and assets are insufficient to cover payment obligations and living expenses. Previous research shows that over-indebtedness increases the risk of various adverse health effects. However, its association with sleep problems has not yet been examined. The objective of this study was to investigate the association between over-indebtedness and sleep problems and sleep medication use.

METHODS

A cross-sectional study on over-indebtedness (OID survey) was conducted in 70 debt advisory centres in Germany in 2017 that included 699 over-indebted respondents. The survey data were combined with the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). We limited analyses to participants with complete data on all sleep variables (OID: n = 538, DEGS1: n = 7447). Descriptive analyses and logistic regression analyses were used to examine the association between over-indebtedness and difficulty initiating and maintaining sleep, and sleep medication use.

RESULTS

A higher prevalence of sleep problems and sleep medication use was observed among over-indebted individuals compared to the general population. After adjustment for socio-economic and health factors (age, sex, education, marital status, employment status, subjective health status and mental illness), over-indebtedness significantly increased the risk of difficulties with sleep onset (adjusted odds ratio (aOR) 1.79, 95%-confidence interval (CI) 1.45-2.21), sleep maintenance (aOR 1.45, 95%-CI 1.17-1.80) and sleep medication use (aOR 3.94, 95%-CI 2.96-5.24).

CONCLUSIONS

Evidence suggests a strong association between over-indebtedness and poor sleep and sleep medication use independent of conventional socioeconomic measures. Considering over-indebtedness in both research and health care practice will help to advance the understanding of sleep disparities, and facilitate interventions for those at risk.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013100 (OID survey, ArSemü); Date of registration: 23.10.2017; Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Prevalence and predictors of having no general practitioner - analysis of the German health interview and examination survey for adults (DEGS1)

BACKGROUND

Although patients in Germany are generally free to choose their primary healthcare provider, this role should mainly be assumed by general practitioners (GPs). While some predictors of the frequency of use of GP services have been reported in international studies, there is still a lack in knowledge what could deter people from contacting a GP in Germany. To improve healthcare, it is important to identify characteristics of people without a GP.

METHODS

This cross-sectional analysis was based on the first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1) conducted by the Robert Koch Institute in 2008-2011. Descriptive analyses and multiple logistic regression by gender were performed to analyze the association between having no GP and age, gender, residential area, socioeconomic status (SES), marital status, working hours per week, general state of health, chronic diseases and health insurance.

RESULTS

Overall, 9.5% (95% confidence interval (CI): 8.4-10.7) of the 7755 participants stated to have no GP, more often men (11.4%) than women (7.6%). Life in urban areas (big cities vs. rural: adjusted odds ratio (aOR): 2.9, 95% CI: 2.1-3.9), younger age (18-29 years vs. 65-79 years: aOR: 4.4, 95% CI: 2.5-7.7) and the presence of chronic diseases (yes vs. no: aOR: 0.4, 95% CI: 0.3-0.6) showed significant associations of not having a GP. For men, the type of health insurance (private vs. statutory: aOR: 2.1, 95% CI: 1.5-3.0; other vs. statutory: aOR: 2.1, 95% CI: 1.4-3.1) and for women, SES (low vs. medium: aOR: 1.8, 95% CI: 1.2-2.7; high vs. medium: aOR: 2.1, 95% CI: 1.4-3.0) increased the risk of having no GP.

CONCLUSIONS

Our analysis offers new insights into the use of GPs in Germany and revealed differences between men and women. Public health strategies regarding access to a GP have to focus on men and on women with a low SES. Further analyses are needed to determine whether men with private health insurance prefer to consult a specialist rather than a GP. For young adults, improving the transition process from a pediatrician to a GP could fill a gap in health care.

[Palliative care of patients receiving opioid substitution therapy]

Patients with opioid use disorder survive longer and reach higher ages due to harm reduction and maintenance programs. Therefor and because of concomitant comorbidities there is an increased incidence of life-limiting diseases. Thus, increasing numbers of patients with opioid use disorder or in maintenance programs will require palliative care. However, both inpatient and outpatient service providers are uncertain about providing palliative care for these patients. Home-care teams and inpatient hospices have been known to refuse admission for patients with opioid use disorder. Providing medical care to patients receiving substitution therapy can be challenging because maintenance programs require strict compliance with their rules and regulations; however, an individualized approach with knowledge of basic legal requirements enables good palliative care. In this manner, it is possible to ensure healthcare for these aging patients.

Opioid use disorder in chronic non-cancer pain in Germany: a cross sectional study

OBJECTIVES

The DSM-5 diagnosis 'opioid use disorder' (OUD) was established to better describe and detect significant impairment or distress related to opioid use. There is no data on rates of OUD in chronic non-cancer pain (CNCP) in European countries. Therefore, our objective was to screen patients in specialised pain centres for signs of OUD.

DESIGN

Cross-sectional questionnaire study.

SETTING

Four outpatient pain clinics in the area of Bonn, Germany.

PARTICIPANTS

n=204 patients participated in the study (response rate: 87.9%). All adult patients with opioid pain therapy >6 months for CNCP were included. Excluded were patients with malignant disease, patients who could not collect their prescription themselves due to age or multimorbidity and patients on opioid-maintenance therapy.

PRIMARY AND SECONDARY OUTCOME MEASURE

Primary outcome measure was the proportion of patients with mild to severe OUD.

RESULTS

One-fourth (26.5%) of participants were diagnosed with OUD. Moderate to severe disorder was found in 9.3. Young age was the only connected risk factor (OR 0.96 [95% CI 0.94 to 0.99], p: 0.003).

CONCLUSIONS

OUD is a relevant diagnosis in patients on long-term opioid therapy for CNCP in the Bonn area. Careful follow-up by the attending physicians is advisable, especially in patients with moderate or severe disorder.